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mercoledì 27 maggio 2015

EARLY last month, a triple suicide
was reported in the seaside town of Civitanova Marche, Italy. A married
couple, Anna Maria Sopranzi, 68, and Romeo Dionisi, 62, had been
struggling to live on her monthly pension of around 500 euros (about
$650), and had fallen behind on rent.

Because
the Italian government’s austerity budget had raised the retirement
age, Mr. Dionisi, a former construction worker, became one of Italy’s
esodati (exiled ones) — older workers plunged into poverty without a
safety net. On April 5, he and his wife left a note on a neighbor’s car
asking for forgiveness, then hanged themselves in a storage closet at
home. When Ms. Sopranzi’s brother, Giuseppe Sopranzi, 73, heard the
news, he drowned himself in the Adriatic.

The
correlation between unemployment and suicide has been observed since
the 19th century. People looking for work are about twice as likely to
end their lives as those who have jobs.

In the
United States, the suicide rate, which had slowly risen since 2000,
jumped during and after the 2007-9 recession. In a new book, we estimate
that 4,750 “excess” suicides — that is, deaths above what pre-existing
trends would predict — occurred from 2007 to 2010. Rates of such
suicides were significantly greater in the states that experienced the
greatest job losses. Deaths from suicide overtook deaths from car
crashes in 2009.

Angus Greig

If
suicides were an unavoidable consequence of economic downturns, this
would just be another story about the human toll of the Great Recession.
But it isn’t so. Countries that slashed health and social protection
budgets, like Greece, Italy and Spain, have seen starkly worse health
outcomes than nations like Germany, Iceland and Sweden, which maintained
their social safety nets and opted for stimulus over austerity.
(Germany preaches the virtues of austerity — for others.)

As
scholars of public health and political economy, we have watched aghast
as politicians endlessly debate debts and deficits with little regard
for the human costs of their decisions. Over the past decade, we mined
huge data sets from across the globe to understand how economic shocks —
from the Great Depression to the end of the Soviet Union to the Asian
financial crisis to the Great Recession — affect our health. What we’ve
found is that people do not inevitably get sick or die because the
economy has faltered. Fiscal policy, it turns out, can be a matter of
life or death.

At one extreme is Greece,
which is in the middle of a public health disaster. The national health
budget has been cut by 40 percent since 2008, partly to meet
deficit-reduction targets set by the so-called troika — the
International Monetary Fund, the European Commission and the European
Central Bank — as part of a 2010 austerity package. Some 35,000 doctors,
nurses and other health workers have lost their jobs. Hospital
admissions have soared after Greeks avoided getting routine and
preventive treatment because of long wait times and rising drug costs.
Infant mortality rose by 40 percent. New H.I.V. infections more than
doubled, a result of rising intravenous drug use — as the budget for
needle-exchange programs was cut. After mosquito-spraying programs were
slashed in southern Greece, malaria cases were reported in significant
numbers for the first time since the early 1970s.

In
contrast, Iceland avoided a public health disaster even though it
experienced, in 2008, the largest banking crisis in history, relative to
the size of its economy. After three main commercial banks failed,
total debt soared, unemployment increased ninefold, and the value of its
currency, the krona, collapsed. Iceland became the first European
country to seek an I.M.F. bailout since 1976. But instead of bailing out
the banks and slashing budgets, as the I.M.F. demanded, Iceland’s
politicians took a radical step: they put austerity to a vote. In two
referendums, in 2010 and 2011, Icelanders voted overwhelmingly to pay
off foreign creditors gradually, rather than all at once through
austerity. Iceland’s economy has largely recovered, while Greece’s
teeters on collapse. No one lost health care coverage or access to
medication, even as the price of imported drugs rose. There was no
significant increase in suicide. Last year, the first U.N. World Happiness Report ranked Iceland as one of the world’s happiest nations.

Skeptics
will point to structural differences between Greece and Iceland.
Greece’s membership in the euro zone made currency devaluation
impossible, and it had less political room to reject I.M.F. calls for
austerity. But the contrast supports our thesis that an economic crisis
does not necessarily have to involve a public health crisis.

Somewhere
between these extremes is the United States. Initially, the 2009
stimulus package shored up the safety net. But there are warning signs —
beyond the higher suicide rate — that health trends are worsening.
Prescriptions for antidepressants have soared. Three-quarters of a
million people (particularly out-of-work young men) have turned to binge
drinking. Over five million Americans lost access to health care in the
recession because they lost their jobs (and either could not afford to
extend their insurance under the Cobra law or exhausted their
eligibility). Preventive medical visits dropped as people delayed
medical care and ended up in emergency rooms. (President Obama’s health
care law expands coverage, but only gradually.)

The
$85 billion “sequester” that began on March 1 will cut nutrition
subsidies for approximately 600,000 pregnant women, newborns and infants
by year’s end. Public housing budgets will be cut by nearly $2 billion
this year, even while 1.4 million homes are in foreclosure. Even the
budget of the Centers for Disease Control and Prevention, the nation’s
main defense against epidemics like last year’s fungal meningitis
outbreak, is being cut, by $293 million this year.

To
test our hypothesis that austerity is deadly, we’ve analyzed data from
other regions and eras. After the Soviet Union dissolved, in 1991,
Russia’s economy collapsed. Poverty soared and life expectancy dropped,
particularly among young, working-age men. But this did not occur
everywhere in the former Soviet sphere. Russia, Kazakhstan and the
Baltic States (Estonia, Latvia and Lithuania) — which adopted economic
“shock therapy” programs advocated by economists like Jeffrey D. Sachs
and Lawrence H. Summers — experienced the worst rises in suicides, heart
attacks and alcohol-related deaths.

Countries
like Belarus, Poland and Slovenia took a different, gradualist
approach, advocated by economists like Joseph E. Stiglitz and the former
Soviet leader Mikhail S. Gorbachev. These countries privatized their
state-controlled economies in stages and saw much better health outcomes
than nearby countries that opted for mass privatizations and layoffs,
which caused severe economic and social disruptions.

Like
the fall of the Soviet Union, the 1997 Asian financial crisis offers
case studies — in effect, a natural experiment — worth examining.
Thailand and Indonesia, which submitted to harsh austerity plans imposed
by the I.M.F., experienced mass hunger and sharp increases in deaths
from infectious disease, while Malaysia, which resisted the I.M.F.’s
advice, maintained the health of its citizens. In 2012, the I.M.F.
formally apologized for its handling of the crisis, estimating that the
damage from its recommendations may have been three times greater than
previously assumed.

America’s experience of
the Depression is also instructive. During the Depression, mortality
rates in the United States fell by about 10 percent. The suicide rate
actually soared between 1929, when the stock market crashed, and 1932,
when Franklin D. Roosevelt was elected president. But the increase in
suicides was more than offset by the “epidemiological transition” —
improvements in hygiene that reduced deaths from infectious diseases
like tuberculosis, pneumonia and influenza — and by a sharp drop in
fatal traffic accidents, as Americans could not afford to drive.
Comparing historical data across states, we estimate that every $100 in
New Deal spending per capita was associated with a decline in pneumonia
deaths of 18 per 100,000 people; a reduction in infant deaths of 18 per
1,000 live births; and a drop in suicides of 4 per 100,000 people.

OUR
research suggests that investing $1 in public health programs can yield
as much as $3 in economic growth. Public health investment not only
saves lives in a recession, but can help spur economic recovery. These
findings suggest that three principles should guide responses to
economic crises.

First, do no harm: if
austerity were tested like a medication in a clinical trial, it would
have been stopped long ago, given its deadly side effects. Each nation
should establish a nonpartisan, independent Office of Health
Responsibility, staffed by epidemiologists and economists, to evaluate
the health effects of fiscal and monetary policies.

Second,
treat joblessness like the pandemic it is. Unemployment is a leading
cause of depression, anxiety, alcoholism and suicidal thinking.
Politicians in Finland and Sweden helped prevent depression and suicides
during recessions by investing in “active labor-market programs” that
targeted the newly unemployed and helped them find jobs quickly, with
net economic benefits.

Finally, expand investments
in public health when times are bad. The cliché that an ounce of
prevention is worth a pound of cure happens to be true. It is far more
expensive to control an epidemic than to prevent one. New York City
spent $1 billion in the mid-1990s to control an outbreak of
drug-resistant tuberculosis. The drug-resistant strain resulted from the
city’s failure to ensure that low-income tuberculosis patients
completed their regimen of inexpensive generic medications.

One
need not be an economic ideologue — we certainly aren’t — to recognize
that the price of austerity can be calculated in human lives. We are not
exonerating poor policy decisions of the past or calling for universal
debt forgiveness. It’s up to policy makers in America and Europe to
figure out the right mix of fiscal and monetary policy. What we have
found is that austerity — severe, immediate, indiscriminate cuts to
social and health spending — is not only self-defeating, but fatal.

Correction: May 25, 2013

An
Op-Ed essay on May 13 about the health effects of economic austerity
misstated cuts to the budget of the Centers for Disease Control and
Prevention. The sequester will cut the budget by $293 million this year,
not “at least $18 million.” (The $18 million represents cuts to a
C.D.C. immunization program.)

David Stuckler, a senior research leader in sociology at Oxford, and Sanjay Basu, an assistant professor of medicine and an epidemiologist in the Prevention Research Center at Stanford, are the authors of “The Body Economic: Why Austerity Kills.”